Sentinel event statistics released for first half of 2020

Through the first six months of 2020, The Joint Commission reviewed a total of 437 sentinel events. The majority — 372 or 85% — were voluntarily self-reported by an accredited or certified organization.

 

In accordance with the Sentinel Event Policy, and as required by Leadership (LD) Standard LD.03.09.01, accredited organizations must review all sentinel events and implement risk reduction strategies to prevent recurrence.

 

Less than an estimated 2% of all sentinel events are reported to The Joint Commission. Of these, 60% (9,422 of 15,770 events) have been self-reported since 2005. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The most frequently reported types of sentinel events reported from Jan. 1 through June 30 were from the following categories:

• Care management
• Surgical or invasive procedures
• Unassigned events at the time of the report
• Suicide
• Protection events
• Environment events
• Product or device

 

While COVID-19 has presented significant challenges for all health care organizations, the number of sentinel events remained comparable to 2019.

 

“As COVID-19 uniquely challenged our accredited health care organizations, future studies will be required to fully quantify its true impact as a causative factor in sentinel events,” stated Raji Thomas, DNP, MBA, CPHQ, CPPS, director of the Office of Quality and Patient Safety, The Joint Commission.

 

The patient safety specialists in the Joint Commission’s Office of Quality and Patient Safety work with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk.

 

“Our patient safety specialists have been sensitive to the unprecedented stressors that health care organizations face because of the pandemic,” Thomas stated. “Our department strives to be nimble and accommodating to meet the individualized needs of organizations as they manage competing priorities. We appreciate that health care organizations continue to find value in working with The Joint Commission to evaluate harm events and implement sustainable mitigation plans to prevent recurrences while managing these unfamiliar crisis situations.”

 

Learn more about sentinel events or call the Office of Quality and Patient Safety at 630-792-3700.